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VOLUME

23

NUMBER

16

JUNE

2005

JOURNAL OF CLINICAL ONCOLOGY

O R I G I N A L

R E P O R T

Significantly Higher Pathologic Complete Remission


Rate After Neoadjuvant Therapy With Trastuzumab,
Paclitaxel, and Epirubicin Chemotherapy: Results of a
Randomized Trial in Human Epidermal Growth Factor
Receptor 2Positive Operable Breast Cancer
Aman U. Buzdar, Nuhad K. Ibrahim, Deborah Francis, Daniel J. Booser, Eva S. Thomas,
Richard L. Theriault, Lajos Pusztai, Marjorie C. Green, Banu K. Arun, Sharon H. Giordano,
Massimo Cristofanilli, Debra K. Frye, Terry L. Smith, Kelly K. Hunt, Sonja E. Singletary,
Aysegul A. Sahin, Michael S. Ewer, Thomas A. Buchholz, Donald Berry, and Gabriel N. Hortobagyi
From the Departments of Breast
Medical Oncology, Biostatistics,
Surgical Oncology, Pathology, Cardiology, and Radiation Oncology, The
University of Texas M.D. Anderson
Cancer Center, Houston, TX.
Submitted July 8, 2004; accepted
November 28, 2004.
Supported in part by research grants
from Genentech, Pfizer, and Bristol
Myers Squibb.
Authors disclosures of potential conflicts of interest are found at the end of
this article.
Address reprint requests to Aman U.
Buzdar, MD, Department of Breast
Medical Oncology, The University of
Texas M.D. Anderson Cancer Center,
1515 Holcombe Blvd, Unit 424,
Houston, TX 77030; e-mail:
abuzdar@mdanderson.org.
2005 by American Society of Clinical
Oncology
0732-183X/05/2316-3676/$20.00
DOI: 10.1200/JCO.2005.07.032

Purpose
The objective of this study was to determine whether the addition of trastuzumab to
chemotherapy in the neoadjuvant setting could increase pathologic complete response (pCR)
rate in patients with human epidermal growth factor receptor 2 (HER2) positive disease.
Patients and Methods
Forty-two patients with HER2-positive disease with operable breast cancer were randomly
assigned to either four cycles of paclitaxel followed by four cycles of fluorouracil, epirubicin,
and cyclophosphamide or to the same chemotherapy with simultaneous weekly trastuzumab for 24 weeks. The primary objective was to demonstrate a 20% improvement in pCR
(assumed 21% to 41%) with the addition of trastuzumab to chemotherapy. The planned
sample size was 164 patients.
Results
Prognostic factors were similar in the two groups. After 34 patients had completed therapy,
the trials Data Monitoring Committee stopped the trial because of superiority of trastuzumab plus chemotherapy. pCR rates were 25% and 66.7% for chemotherapy (n 16) and
trastuzumab plus chemotherapy (n 18), respectively (P .02). The decision was based on
the calculation that, if study continued to 164 patients, there was a 95% probability that
trastuzumab plus chemotherapy would be superior. Of the 42 randomized patients, 26% in
the chemotherapy arm achieved pCR compared with 65.2% in the trastuzumab plus
chemotherapy arm (P .016). The safety of this approach is not established, although no
clinical congestive heart failure was observed. A more than 10% decrease in the cardiac
ejection fraction was observed in five and seven patients in the chemotherapy and
trastuzumab plus chemotherapy arms, respectively.
Conclusion
Despite the small sample size, these data indicate that adding trastuzumab to chemotherapy,
as used in this trial, significantly increased pCR without clinical congestive heart failure.
J Clin Oncol 23:3676-3685. 2005 by American Society of Clinical Oncology

INTRODUCTION

Systemic therapy is an integral part of the


multidisciplinary curative treatment of pri-

mary breast cancer and results in significant


reductions in risk of recurrence and death.1-3
Combination chemotherapy regimens administered as postoperative adjuvant therapy

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Effect of Trastuzumab on pCR in Breast Cancer

are superior to single-agent chemotherapy, and anthracyclinecontaining regimens are superior to nonanthracyclinecontaining combinations. Primary induction chemotherapy
has been evaluated in a number of studies in patients with
breast cancer.4 Randomized studies indicated that the survival
benefit from particular treatment regimens is similar, regardless of whether the treatment is administered preoperatively or
postoperatively. A practical benefit of preoperative therapy is
that it will downstage the primary tumor in most women,
allowing a higher rate of breast preservation. It also provides an
in vivo assessment of tumor response to the particular drug
regimen and, hence, an opportunity to optimize therapy.5
Furthermore, pathologic complete response (pCR) after preoperative therapy is a powerful surrogate of long-term diseasefree survival. It is hypothesized that a regimen that produces
higher rates of pCR in the neoadjuvant treatment setting will
also result in higher rates of long-term cure.
Human epidermal growth factor receptor 2 (HER2) is
overexpressed in 25% to 30% of breast cancers, suggesting a
role for overexpression in tumorigenesis.6 This overexpression is most commonly the result of gene amplification.
Several lines of evidence support the role of HER2 overexpression in the pathogenesis and poor clinical outcome of
human tumors. A number of these studies have shown that
breast cancers that overexpress HER2 have a more aggressive course and higher relapse and mortality rates. HER2
overexpression in retrospective analyses of adjuvant
studies was also associated with resistance to cyclophosphamide, methotrexate, and fluorouracil chemotherapy.7,8 With regard to response to hormonal therapies and
anthracycline-based chemotherapy, the role of HER2
overexpression is unclear.9,10
Trastuzumab (Herceptin; Genentech Inc, South San
Francisco, CA) is a humanized monoclonal antibody directed against the extracellular domain of HER2.11 Trastuzumab as a single agent has modest antitumor activity.12-14
In phase III randomized trials, trastuzumab in combination
with standard chemotherapy (paclitaxel, docetaxel or doxorubicin, and cyclophosphamide combinations) demonstrated improvement in time to progression, overall
response, and duration of response and a favorable impact
on survival compared with the same chemotherapy alone
as therapy for metastatic breast cancer overexpressing
HER2.15-17 Cardiac dysfunction was observed in 27% of
patients treated with trastuzumab and anthracycline-based
combination therapy.15 No randomized preoperative study
has been performed with trastuzumab. Given the enhanced
antitumor activity in these studies, we designed a study in
which patients with HER2-positive operable breast cancer
were randomly assigned to either chemotherapy (sequential
paclitaxel and fluorouracil, epirubicin, and cyclophosphamide [FEC]) with simultaneous weekly trastuzumab for 24
weeks or chemotherapy alone. The choice of chemotherapeutic agents was based on what we consider to be among

the most active agents in breast cancer. The goal of the study
was to demonstrate that the addition of trastuzumab to a
complete 6-month preoperative chemotherapy regimen
will increase pCR rate two-fold compared with chemotherapy alone. We selected epirubicin as part of the combination regimen in an effort to reduce cardiac toxicities
compared with those attributed to trastuzumab and doxorubicin combination. The results of this prospective randomized phase III study were recently presented,18 and
complete results are included in this article.
PATIENTS AND METHODS
Patients with histologically confirmed invasive, but noninflammatory, carcinoma of the breast with stage II to IIIA disease were
included in this study. Histologic confirmation of invasive tumor
was performed by core needle biopsy. Fine-needle aspiration of
clinically suspicious lymph nodes was performed. All tumors were
HER2 positive by fluorescence in situ hybridization (FISH) or
showed 3 overexpression by immunohistochemistry. Before initiation of therapy, all patients underwent staging evaluation,
which included a complete history, physical examination, CBC,
chemistry profile, chest radiograph, ultrasound or computed tomography scan of the liver, and a bone scan. Mammography of
both breasts was performed, and additional breast and axillary
assessment of the tumor site was conducted by ultrasound. Before
entry onto the study, each patient was informed about the investigational nature of the study, and a written informed consent,
which was approved by the institutional review board, was obtained. All patients were required to have adequate bone marrow
function as defined by an absolute granulocyte count of more than
1,500/L and platelet count of more than 100,000/L. Patients
had to have adequate liver function, with bilirubin within normal
laboratory values. In addition, patients had to have adequate renal
function, which was defined as serum creatinine less than 2.5
mg/100 mL. Cardiac evaluation included a baseline echocardiogram or a cardiac scan. Patients with a history of uncompensated
congestive heart failure or a cardiac ejection fraction less than 45%
were excluded. Each patient was reviewed in a multidisciplinary
conference with designation of whether breast conservation was a
reasonable surgical option before treatment was initiated.
All patients were prospectively registered into our central
research database. Patients were randomly assigned to receive
either chemotherapy alone or the same chemotherapy with trastuzumab on a weekly basis for 24 weeks. Patients had a physical
examination of breasts and regional lymph node basins before
each cycle of chemotherapy. Antitumor activity was evaluated
with imaging studies after four cycles of chemotherapy (at the
completion of paclitaxel) and before surgery (at the completion of
FEC). Tumor measurements were documented after the first 12
weeks of paclitaxel and at the completion of FEC therapy to
determine the best clinical response before local therapy. CBCs,
differential counts, and platelet counts were repeated weekly to
monitor the myelotoxicity of chemotherapy in the first cycle, and
subsequently, blood counts were performed on day 1 of each cycle.
Cardiac evaluation was performed at baseline and then repeated
after completion of paclitaxel and then again at the completion of
FEC therapy. If there was a marked response to chemotherapy
after one or more cycles of chemotherapy, the tumor site was
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Buzdar et al

marked with a stainless steel marker placed under ultrasound


guidance. Follow-up ultrasound and mammography were performed after four cycles of paclitaxel and again after four cycles of
FEC. After completion of chemotherapy and surgical and/or radiation therapy, patients with estrogen receptor (ER) positive
and/or progesterone receptorpositive tumors received adjuvant
endocrine therapy. Patients were evaluated at 4-month intervals
during the initial 2 years and then at 6-month intervals for the
third year. Mammograms were performed yearly.
Clinical complete remission was defined as disappearance of
all clinical evidence of active tumor per evaluation by physical
examination. Partial response was defined as equal or greater than
50% decrease in measurable lesions for a minimum of 4 weeks as
determined by the product of the longest perpendicular diameters
of the lesion(s). Minor response was defined as a decrease in the
tumor size that did not qualify for partial response, and progressive disease was defined as any increase in tumor size or appearance of new lesions. pCR was defined as no evidence of residual
invasive cancer, both in breast and axilla.
The primary objective of the study was to compare pCR rates
between the two arms. The projected pCR rate with the standard
arm was estimated to be 21% based on previous experience with
similar chemotherapy.19 The study was powered to detect a 20%
improvement in the pCR rate (ie, from 21% to 41%). Accrual of
164 patients was planned. With this number of patients, the study
would have had 80% power to detect a 20% difference (two-sided
type I error 0.05). Patients were assigned to treatment arms
using a stratified blocked randomization, with strata based on age
( 50 years v 50 years) and stage of disease. One interim analysis
was planned when pCR results were known for the first 82 patients. Stopping rules were provided in the event that accumulating evidence indicated a rate of cardiac toxicity more than 3%. All
patients were included in the analysis of response and toxicity.
Toxicities were tabulated by type and grade using the National
Cancer Institute Common Toxicity Criteria, Version 2.0. Toxicity
and response rates were compared using the 2 test. In view of the
apparently high pCR rate in the trastuzumab plus chemotherapy
arm, the data were presented to the M.D. Anderson Data Monitoring Committee (DMC). The DMC requested information on
the patient accrual rate, response, and adverse events by treatment.
The DMC also requested an analysis based on Bayesian predictive
probabilities,20,21 addressing the question of how likely the final
results of the study (ie, after the full planned sample size of 164
patients) would show statistical significance favoring the trastuzumab plus chemotherapy arm.
Chemotherapy
Each patient was to receive four cycles of paclitaxel followed
by four cycles of FEC. Paclitaxel was administered at 225 mg/m2 as
a 24-hour continuous intravenous (IV) infusion; cycles were repeated every 3 weeks for four cycles. Each patient was premedicated with either dexamethasone 20 mg orally, 12 and 6 hours
before administration of paclitaxel, or dexamethasone 20 mg IV
30 minutes before chemotherapy. Patients received diphenhydramine 50 mg IV and cimetidine 300 mg IV 30 minutes before
paclitaxel infusion. The dose and schedule of paclitaxel was selected based on information available at the time of study inception in 1999. At that time, the optimal dose and schedule of
paclitaxel was unclear, and there were data to suggest that a 24hour continuous infusion and somewhat higher doses might be
beneficial compared with short infusion.22,23 These assumptions
today do not seem to be validated. On the basis of current evi3678

dence, the most effective schedule may be weekly administration.19,24 FEC consisted of fluorouracil 500 mg/m2 IV on days 1
and 4, cyclophosphamide 500 mg/m2 IV on day 1 only, and epirubicin 75 mg/m2 on day 1 only. Patients randomly assigned to the
trastuzumab arm of the study received trastuzumab at a dose of 4
mg/kg IV on day 1 of the first treatment cycle, administered over
90 minutes. Subsequent doses of weekly trastuzumab were administered at a dose of 2 mg/kg over 30 minutes. Patients were monitored for 1 hour after the first infusion and for 30 minutes after
subsequent infusions. Trastuzumab was administered before chemotherapy. A total of 24 doses of trastuzumab were administered
on a weekly basis. In the first cycle, trastuzumab was administered
1 day before paclitaxel to monitor any potential infusion reaction;
on subsequent courses, therapies were administered on the same
day if there was no adverse event with the first cycle. After completion of 24 weeks of systemic therapy, patients received local
therapy. After completion of systemic and local therapy, patients
with ER-positive tumors received tamoxifen at a dose of 20 mg
daily or anastrozole 1 mg daily if the patient was postmenopausal.
This was planned for 5 years, regardless of the menopausal status
of the patient.
Dose Modification Criteria
The dose of paclitaxel was reduced by 50% in subsequent
cycles if a patient developed grade 3 neurotoxicity. Patients were
required to have more than 1,500/L granulocytes and more than
100,000/L platelets before the administration of the next cycle of
chemotherapy. Doses of the chemotherapy drugs (both FEC and
paclitaxel) were not altered if the patients lowest granulocyte
count was more than 250/L, there was no other organ toxicity
greater than grade 2, and the lowest platelet count was more than
50,000/L. Patients did not receive prophylactic hematopoietic
growth factor unless neutropenic fever occurred. If a patient experienced neutropenic fever, either on the paclitaxel or the FEC
phase of therapy, granulocyte colony-stimulating factor was added
to the treatment at 5 g/kg on days 5 through 18 or until the
granulocyte count was more than 2000/L, and chemotherapy
dose was not modified. In subsequent cycles, if a patient experienced fever after the addition of granulocyte colony-stimulating
factor, the dose of the drug(s) was reduced by 20%. The dose of the
drug(s) was reduced by 20% if a patient experienced organ toxicity
other than myelosuppression of grade 3.
Local Therapy
After completion of neoadjuvant therapy, each patient was
evaluated. Patients who were considered appropriate candidates
for breast conservation therapy (BCT) were offered segmental
mastectomy (lumpectomy). Patients who were considered inappropriate for BCT or who did not desire BCT underwent total
mastectomy. All patients (mastectomy and BCT) with persistent
axillary disease detected by physical examination or by ultrasonography and verified by ultrasound-guided fine-needle aspiration
underwent axillary lymph node dissection. Patients who were
clinically node-negative after neoadjuvant therapy proceeded to
lymphatic mapping and sentinel lymph node biopsy. Clinically
node-negative patients who showed microscopic residual disease
in the sentinel lymph node(s) were recommended for axillary
lymph node dissection, although some elected to receive postoperative radiation therapy to the regional lymph nodes instead.
All patients treated with a segmental mastectomy received
whole-breast irradiation. The breast was treated with standard
medial and lateral tangent fields using 6 to 15 MV photons to a
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Effect of Trastuzumab on pCR in Breast Cancer

total dose of 50 Gy delivered in 25 fractions. Subsequently, the


tumor bed was treated with an additional 10 Gy in five fractions
with electrons. Regional nodal irradiation to the supraclavicular
fossa-axillary apex was used in patients with clinical stage III
disease, in patients with four or more positive lymph nodes, and in
selected patients with one to three positive lymph nodes. Radiation treatments were not offered to patients with initial clinical
stage II breast cancer who were treated with mastectomy and had
negative lymph nodes. Radiation treatment of the chest wall and
draining lymphatics was used for patients with stage III disease,
patients with four or more positive lymph nodes, and selected
patients with one to three positive lymph nodes. In these patients,
the chest wall was typically treated with opposed lateral tangent
fields matched to a medial electron field that included the
internal mammary lymph nodes and a separate matched photon field that treated the supraclavicular fossa-axillary apex.
These regions were treated to 50 Gy in 25 fractions with a
subsequent 10 Gy boost to the chest wall and areas of unresected, initially positive, adenopathy.
Pathologic Evaluation
After chemotherapy, resected specimens were evaluated
by breast pathologists using the standard protocol of The M.D.
Anderson Cancer Center.25,26 In brief, the surgeon oriented the
specimen with sutures and accompanied it to the pathology suite.
In cases showing significant clinical response, the breast resection
specimen was radiographed to identify metallic markers, which
were placed under ultrasound examination before chemotherapy.
The specimen was inked using multiple colors to identify each face
of the specimen. It was then sectioned into 3- to 5-mm slices. The
sliced specimen was radiographed, and a radiologist reviewed
the films to determine the presence and extent of residual tumor.
The pathologist examined the sliced specimen grossly to identify
suspicious areas and note their proximity to margins. The radiographic and pathologic evaluations were discussed with the surgeon who decided whether additional margin should be obtained
or not. Permanent paraffin sections of the suspicious areas and
margins were obtained. The number of sections taken was based
on the gross inspection, radiographic features, and size of the
resection specimen. The entire radiographic abnormality as well as
firm and suspicious-appearing breast tissue was submitted for
histologic evaluation. In general, for nonpalpable (clinical complete response) cases, at least 10 to 15 blocks were examined to
assess the presence of residual microscopic disease. In cases with
residual palpable mass (partial clinical response or no response),
the resection specimen was inked and sectioned into 3- to 5-mm
slices. The pathologist examined the slices and determined the
tumor size and gross evaluation and confirmed the tumor size by
microscopic evaluation. The largest area of residual disease was
included to document the extent of disease in a patient with
multiple foci of persistent invasive cancer. All axillary lymph nodes
were also carefully evaluated by serial gross sectioning. One or two
representative histologic sections were evaluated for lymph nodes
that contained grossly identifiable metastatic carcinoma. Lymph
nodes that did not show grossly identifiable tumor were submitted
for histologic evaluation in their entirety. One representative histologic section was evaluated per paraffin block. Immunohistochemical staining for cytokeratin was not routinely performed on
negative nodes.

RESULTS

Between June 2001 and October 20, 2003, 42 patients were


registered onto this study and randomized. Of those 42
patients, 19 patients were randomly assigned to chemotherapy alone, and 23 patients were assigned to chemotherapy
with trastuzumab. Pretreatment characteristics of the patients in the two groups were similar and are listed in Table
1. The median age was slightly higher for the patients
treated with chemotherapy plus trastuzumab. The distributions by the tumor T and N status were similar in the two
groups, except for one patient who had T3b disease and was
included in the chemotherapy plus trastuzumab arm. Two
patients in the chemotherapy plus trastuzumab arm had
synchronous bilateral breast cancers. Approximately half of
the patients had hormone receptorpositive tumors. Most
patients had HER2/neu status of tumors confirmed by
FISH. For four patients, HER2 status was determined by
immunohistochemistry only. One patient in each arm was
subsequently found to be HER2 negative by FISH.

Table 1. Patient Characteristics


No. of Patients
Characteristic
Age, years
Median
48
Range
25-75
Tumor
T1
T2
T3
T4
Nodal status
N0
N1
N2
Hormonal receptor status
ER positive, PR positive
ER positive, PR negative
ER negative, PR positive
ER negative, PR negative
HER2 status
FISH positive
IHC 3 only
IHC 3, FISH negative
Race
White
African American
Asian
Hispanic

P 3 FEC H
(n 23)

P 3 FEC Alone
(n 19)
52
29-71
2
13
4
0

2
15
5
1

7
12
0

10
12
1

6
4
1
8

6
4
3
10

17
1
1

19
3
1

13
3
2
1

13
1
4
5

Abbreviations: P, paclitaxel; FEC, fluorouracil, epirubicin, and cyclophosphamide; H, trastuzumab; ER, estrogen receptor; PR, progesterone
receptor; HER2, human epidermal growth factor receptor 2; FISH,
fluorescence in situ hybridization; IHC, immunohistochemistry.

Two patients in the trastuzumab arm had synchronous bilateral disease.

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Investigators were aware of the pathology results as


each patient underwent the surgery phase of the trial. A high
complete response rate was noted among early patients who
completed surgical therapy. In October 2003, the DMC
reviewed the study results. At the time that 42 patients had
been registered onto the study, the pathology results were
known for the first 34 patients. A formal interim analysis
was not scheduled until the results for the first 82 patients
were available, which was estimated to require at least 3
more years of accrual. Therefore, the DMC requested an
extraordinary interim analysis based on Bayesian predictive
probabilities and uniform prior distributions.20,21 In particular, the DMC requested that they be presented with a
calculation of the probability of eventually (ie, after the full
sample size of 164 patients), showing statistical significance
in pCR rates favoring the trastuzumab plus chemotherapy
arm, based on the currently available information. This
probability was 95%. The DMC found this to be compelling
evidence that the study had reached its primary objective
and recommended that accrual be suspended.
The pCR data for the first 34 patients, as reviewed by
the DMC, and for all 42 patients randomized are listed in
Table 2. Among the total patients, 26.3% of patients in the
chemotherapy alone arm achieved pCR compared with
65.2% of the patients treated with trastuzumab plus
chemotherapy. This difference was statistically significant
(P .016). The 95% CI for the 65.2% pCR rate observed on
the trastuzumab plus chemotherapy arm ranged from 43%
to 84%. An update of the Bayesian analysis incorporating
results for 42 patients indicated a 96% probability that the
trastuzumab plus chemotherapy arm would be found superior if accrual were continued to 164 patients. Of the patients who achieved pCR, one in the chemotherapy alone
arm and five in the trastuzumab plus chemotherapy arm
had residual ductal carcinoma-in-situ.
The pCR rate by hormone receptor status in the two
arms was also evaluated. Patients with hormone receptor
positive and negative disease had similar pCR rates compared with the overall population. Both ER-positive and
ER-negative tumors treated with trastuzumab plus chemotherapy had higher pCR rates compared with the chemotherapy alone subgroups (Table 2). The extent of the
residual disease in the breast (according to the largest onedimensional measurement) and lymph node(s) is summarized in Table 2. For patients treated with trastuzumab plus
chemotherapy, the size of residual tumors in the breast was
significantly smaller compared with tumors of patients
treated with chemotherapy alone. The difference in extent
of residual disease in the lymph nodes, as measured by
number of positive nodes, was not statistically significant.
The median number of nodes evaluated histologically was
similar between the two groups. Patients who had sentinel
node biopsy had a median number of four nodes (range,
four to five nodes) and three nodes (range, one to five
3680

nodes) in the chemotherapy alone arm (n 7) and chemotherapy with trastuzumab arm (n 9), respectively.
Among patients who had axillary dissection, the median
number of nodes was 16 (range, 12 to 26 nodes) and 16
(range, eight to 20 nodes) in the chemotherapy alone arm
(n 12) and chemotherapy with trastuzumab arm
(n 14), respectively. BCT was performed in 10 (52.6%)
and 13 (56.5%) patients in the chemotherapy alone arm and
chemotherapy with trastuzumab arm, respectively.
Clinical Response
The clinical response data are listed in Table 2. The
clinical response was assessed by physical evaluation of the
breast and nodes. Nine patients (47.4%) in the chemotherapy alone arm and 20 patients (86.9%) in the trastuzumab
plus chemotherapy arm had clinical complete response.
Most of the pCRs were observed in patients who had clinical
complete responses. A small number of patients clinically
judged to have partial response or no change in their disease
status had pCR. Imaging studies included mammogram
and ultrasound before surgery. In a number of patients who
had pCRs, there were persistent abnormalities on imaging
studies (Table 2). A number of patients with partial response on the paclitaxel phase of therapy achieved clinical
complete response on the FEC phase of therapy. Response
data are listed in Table 3 by each phase of therapy (paclitaxel
and FEC).
Safety Data
The toxicity data are listed in Table 4. A higher fraction
of patients treated with trastuzumab plus chemotherapy
experienced grade 4 neutropenia during the paclitaxel
phase of the therapy. A small number of patients had neutropenic fever, which required hospitalization for IV antibiotics. There were no treatment-related deaths. The
chemotherapy dose was reduced because of neutropenia in
five patients on the chemotherapy alone arm and 10 patients on the trastuzumab plus chemotherapy arm. Among
the five patients in the chemotherapy arm who had dose
reduction, one had a pCR. Ten patients had dose reduction
because of neutropenia during the paclitaxel phase of therapy in the trastuzumab plus chemotherapy arm, and of
those patients, eight had pCR. In the chemotherapy alone
group, dose reduction was performed in one patient during
the FEC phase of therapy. In the FEC phase of chemotherapy in the trastuzumab plus chemotherapy group, one patient had dose reduction because of neutropenia, and that
patient had pCR. Three patients in each treatment arm had
dose reduction for reasons other than myelotoxicity. A
small number of patients experienced minor allergic reactions that did not require dose modifications. Patients were
managed with additional appropriate premedications. In
this small study, none of the patients developed clinical
congestive heart failure (95% CI, 0% to 14.8%). With this
number of patients, the probability of congestive heart
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Effect of Trastuzumab on pCR in Breast Cancer

Table 2. Response by Treatment for All 42 Patients Except Where Noted


No. of Patients
Response
pCR
Initial 34 patients
%
95% CI
All 42 patients
%
95% CI
pCR by hormonal receptor status, %
Positive
Negative
Extent of residual disease by treatment
Residual disease in breast
None
1 cm
1-3 cm
3 cm
No. of positive nodes
0
1-3
4-10
10
Physical evaluation
Complete response
Clinical response
pCR
Partial response
Clinical response
pCR
Progressive disease
Clinical response
pCR
Unknown
Clinical response
pCR
Imaging studies, mammogram and ultrasound
Complete response
Imaging response
pCR
Partial response
Imaging response
pCR
No change
Imaging response
pCR
Progressive disease
Imaging response
pCR
Unknown
Imaging response
pCR

P 3 FEC H
(n 23)

P 3 FEC Alone
(n 19)

25
7.3 to 52.4

66.7
41 to 87

.05

26.3
9.1 to 51.2

65.2
43 to 84

.016

27.2
25

61.5
70

5
3
9
2

15
5
1
2

.01

15
2
2
0

20
3
0
0

.25

9
4

21
13

9
1

1
1

1
0

0
0

0
0

1
1

5
4

12
7

11
1

10
7

1
0

1
1

1
0

0
0

1
0

0
0

Abbreviations: P, paclitaxel; FEC, fluorouracil, epirubicin, and cyclophosphamide; H, trastuzumab; pCR, pathologic complete response.

Reviewed by Data Monitoring Committee.

failure being 10% or higher is ruled out with a type II error


rate of 8.9%. A greater than 10% decrease in the left ventricular ejection fraction was observed in five and seven patients in the chemotherapy alone and trastuzumab plus

chemotherapy arms, respectively. Left ventricular ejection


fraction returned to baseline values in those patients who
had follow-up cardiac studies, except for one patient for
whom the ejection fraction remains in the low normal
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Table 3. Clinical Response by Phase of Therapy


P 3 FEC H (No. of patients)

P 3 FEC (No. of patients)


P

FEC

Physical evaluation
CR 6
PR 11
MR 1
NC 1
Evaluation by ultrasound
CR 2
PR 14
MR 1
NC 2

FEC

CR 5, PD 1
CR 4, PR 7
PR 1
PR 1

CR 14
PR 7
MR 1
NC 1

CR 14
CR 6, PR 1
Unknown 1
CR 1

CR 2
CR 3, PR 9, PD 1, unknown 1
PR 1
PR 1, NC 1

CR 4
PR 18
MR 1

CR 3, unknown 1
CR 9, PR 9
PR 1

Abbreviations: P, paclitaxel; FEC, fluorouracil, epirubicin, and cyclophosphamide; H, trastuzumab; CR, complete response; PR, partial response; MR, minor
response; NC, no change; PD, progressive disease.

These patients did not have documentation of response after FEC.

range. Troponin T levels were evaluated at 3-week intervals


during therapy. Values remained in the normal range for all
patients, except for one patient on trastuzumab who had a
single abnormal value.
Thus far, only one patient has developed recurrent
disease, and that patient was on the chemotherapy alone
arm. The median length of patient follow-up was 20
months (range, 8.8 to 36.6 months).
DISCUSSION

The objective of this prospective study was to determine the


impact of the addition of trastuzumab on the pCR rate

Table 4. Adverse Events


No. of Patients

Event
Grade 4 neutropenia
Neutropenic fever
Neutropenic infections
Hospitalization
Nonneutropenic infections
Chemotherapy dose reduction as a result
of neutropenia
Allergic reactions, no therapy modification
Cardiac safety data
CHF
10% decrease in ejection fraction
Decrease on P
Decrease on FEC
Improvement in ejection fraction on
follow-up evaluation
Abnormal troponin-T

P 3 FEC
Alone
(n 19)

P 3 FEC H
(n 23)

11
8
3
1
4
5

21
8
5
3
7
10

0
5
0
5
2

0
7
4
3
3

Abbreviations: P, paclitaxel; FEC, fluorouracil, epirubicin, and cyclophosphamide; H, trastuzumab; CHF, congestive heart failure.

P .03.

3682

when patients with primary breast cancer were treated with


sequential neoadjuvant paclitaxel and FEC chemotherapy.
The pCR rate was 65% for patients treated with trastuzumab plus chemotherapy compared with 26% for patients
treated with chemotherapy alone. For women treated with
anthracycline-based neoadjuvant chemotherapy, pCR has
been shown to predict improved disease-free and overall
survival when compared with patients with less than
pCR.27-29 However, it remains to be determined whether
increased pCR rate, as observed in this study with the sequential use of two chemotherapy regimens and limited
exposure to trastuzumab, will result in improved diseasefree and overall survival. A number of phase II studies have
evaluated trastuzumab in the neoadjuvant setting with
nondoxorubicin-containing chemotherapies.30-34 In these
studies, pCR rates have ranged from 19% to 35%. In this
study, our objective was to achieve a 20% improvement in
pCR rate with the addition of trastuzumab to chemotherapy. The results of this study demonstrated a higher pCR
rate than anticipated. As a result, the study was modified,
and the control arm was stopped at the recommendation of
the DMC. In the revised, ongoing study, all patients with
HER2-positive disease are being offered chemotherapy plus
trastuzumab. With additional patients, the CI of the pCR
rate will be narrowed, and follow-up of all patients will
provide additional safety data.
Despite the high pCR rate, BCT was performed in only
approximately half of the patients. This may be a reflection
of a number of factors that include persistent abnormalities
on imaging studies and patient preferences. Better imaging modalities or cancer markers are needed that provide
accurate information regarding persistent (or lack
thereof) invasive disease. With this approach, a larger
fraction of patients with no invasive cancer, if accurately
identified before local therapy, may be candidates for
breast preservation.
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Effect of Trastuzumab on pCR in Breast Cancer

Cardiac toxicity has been an ongoing concern related


to the use of trastuzumab in early-stage breast cancer. In
this study, trastuzumab was administered concurrently
with paclitaxel- and epirubicin-based chemotherapy. Since
the publication of the pivotal trial in metastatic, HER2overexpressing breast cancer, it has been known that the
simultaneous combination of doxorubicin and trastuzumab resulted in a high rate of clinical and subclinical
cardiotoxicity, but data from large multicenter trials have
not resulted in toxicity rates sufficiently high to curtail
enrollment.35 On the basis of those results, subsequent
studies, especially those performed in the adjuvant or neoadjuvant setting, have avoided the simultaneous administration of anthracyclines and trastuzumab. However,
retrospective analyses of the correlation of HER2 overexpression and chemotherapy response have suggested that
anthracyclines had an important role in the management of
HER2-overexpressing breast cancer.9,36-42 Therefore, we
reasoned that the simultaneous combination of trastuzumab with an anthracycline could be advantageous, as
long as cardiac toxicity could be prevented or minimized.
There are ongoing studies of combinations that include
trastuzumab with epirubicin or doxorubicin HCl liposome
injection, two anthracyclines with reported lower cardiac
toxicity effects than doxorubicin.43-47 These preliminary
safety data and the intent to limit cumulative dose of the
anthracycline in the sequential combination with a taxane
suggested that the combination with trastuzumab could be
administered safely, without excessive cardiac toxicity. Epirubicin, the anthracycline included in the combination in
this study, has been reported to have a better cardiac safety
margin. There is no evidence of steep dose-dependent response with doxorubicin beyond 50 to 60 mg/m2 in the
adjuvant setting. However, for epirubicin, there is a dosedependent response in the adjuvant setting. Administration
of FEC100, using epirubicin 100 mg/m2 per cycle, results in
significantly improved 10-year survival compared with
FEC50, using epirubicin 50 mg/m2.48 We selected 75 mg/m2
as a safe compromise between efficacy and cardiac safety
because concurrent trastuzumab was planned. Four cycles
of epirubicin at this dose would result in a cumulative dose
of 300 mg/m2, which is approximately one third of the
cardiotoxic threshold of epirubicin. With this approach, we
expected to reduce the risk of cardiac dysfunction. In this
study, the duration of trastuzumab was also limited to 24
weeks. The limited exposure of epirubicin concomitantly
with trastuzumab has not resulted in any clinical cardiac
dysfunction. A small number of patients did show a transient drop in the cardiac ejection fraction; however, cardiac
ejection fractions returned to original normal levels on
follow-up evaluation.
In this study, pCR rates were high both in patients with
hormone receptorpositive and hormone receptornegative disease. This was in contrast to our earlier experience in

patients unselected by HER2 status treated with neoadjuvant therapy. In a retrospective review of more than 1,000
patients with primary breast cancer, pCRs in studies with
anthracycline-based chemotherapies ranged from 2% to
14% (mean, 5%) in patients with hormone receptorpositive disease compared with 7% to 55% (mean, 21%) in
patients with hormone receptornegative disease.49 In that
analysis, the HER2 status of the tumors was not known.
Unlike our previous experience with preoperative chemotherapy, pCR rates in this study were similar for ER-positive
and ER-negative tumors. HER2 status seems to be of more
influence in pCR outcome. Further clinical and laboratory
evaluation of this interaction of ER and HER2 and response to
chemotherapy is warranted. Additional follow-up of these patients and continued accrual on the ongoing trial will provide
additional efficacy and safety data for this treatment approach.
These results represent the highest reported pCR rate in
this patient population. The most logical explanation for this
high pCR rate is the use of two potentially non cross-resistant
chemotherapies administered sequentially in combination
with trastuzumab. Other possibilities include longer duration
of neoadjuvant therapy compared with earlier studies. Additional studies are needed to define the pCR rate with a narrow
CI and establish the cardiac risk of this combination.
Follow-up of our study patients will provide data that will
establish whether pCR rate will translate into high disease-free
and overall survival rates as observed in other neoadjuvant
studies. If the long-term follow-up confirms prolonged overall
survival and low or modest incidence of cardiac toxicity, this
combination may have a favorable risk to benefit ratio for
patients with HER2-positive breast cancer.

Acknowledgment
We thank the following faculty members for their
support of this study: Edgardo Rivera, James L. Murray,
Marguerite F. Rosales, Ronald Walters, Karin Gwyn, and
Vicente Valero.
Authors Disclosures of Potential
Conflicts of Interest
The following authors or their immediate family members have indicated a financial interest. No conflict exists for
drugs or devices used in a study if they are not being evaluated
as part of the investigation. Employment: Michael S. Ewer,
Pfizer. Honoraria: Aman U. Buzdar, Pfizer; Debra K. Fyre,
Pfizer, Pharmacia; Aysegul A. Sahin, Genentech; Michael S.
Ewer, Alza. Research Funding: Aman U. Buzdar, BristolMyers Squibb, Genentech, Pfizer; Banu K. Arun, AstraZeneca,
NCI, Pfizer. For a detailed description of these categories, or
for more information about ASCOs conflict of interest policy,
please refer to the Author Disclosure Declaration and Disclosures of Potential Conflicts of Interest found in Information
for Contributors in the front of each issue.
3683

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Buzdar et al

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